16-100786 R
E VED
"TY°` tots PERMIT PPLICATION
Federal Way FEB 11
/ CITY OF FEDERAL WAY
PERMIT NUMBER / /^ _ _
/ / / ! �. _
-j�/LJ V/ TARGET DATE
SITE ADDRESS SUITE/UNIT#
34.450X RcaF c wwy 5 Li 7)69 g
PROJECT VALUATION ZONING
ASSESSOR'S TAX/PARCEL#
$
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING l ,FIRE PREVENTION
NAME OF PROJECT
r C-�cA apt_ `�ray C(bz"S,..1/4 c.S ►�L .
PROJECT DESCRIPTION 12-E'�l"vG ''i 3 5 inc: 1-0" ate/= ccc+0.6 (kN1 iZC P ar
Detailed description of work to C--"It t ST1A-U., (-SZL Ct 1't-C-'1 r-1.C 4/L wt ?14,1-16Z (..I/7--41-
be
/i-be included on this permit only S/CFevr /c/V/G'4- S'766I /-//2e i4LA/L.+'1
124Af/'L.
NAME PRIMARY PHONE
PROPERTY OWNER
MAILING ADDRESS E-MAIL
CITY STATE ZIP
NAME PHONE
Sys rerms IA/1 S ; /A./G 25'3-`633- /2-Vir
MAILING ADDRESS E-MAIL
CONTRACTOR 1c'(a -t20^S'1 CMGs t1 rJI SC /77-"--C.-
STATE
STATE ZIP FAX
v+c/r/ 14/4 9104/7
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
f=lruz 5wCO 55' .) C / /(, / I(n ly'`67 00(60 04 -10-
NAME
LNAME PRIMARY PHONE
5INtn 'Ns ctoit
APPLICANT MAILING ADDRESS E-MAIL
CITY STATE ZIP FAX
NAME 6444.0./.4A./
PRIMARY PHONE
PROJECT CONTACT / ?7477 C..i4i 4.0.i 4It/ 2 S -`r/ G' 5
(The individual to receive and MAILING ADDRESS E-MAIL
respond to all correspondence C�1,3 TRAC.To C< rVhTrCP ciiLC'SYSTC`rt• 1.3C4A-.car,
concerning this application) CITY STATE ZIP FAX
NAME
PROJECT FINANCING EJ OWNER-FINANCED
Required value of$5,000 or more MAILING ADDRESS,CITY,STATE,ZIP PHONE
(RCW 19.27.095)
I certify under penalty of perjury that I am the property owner or authorized agent of the property owner. I certify that to the best
of my knowledge, the information submitted in support of this permit application is true and correct. I certify that I will comply with
all applicable City of Federal Way regulations pertaining to the work authorized by the issuance of a permit. I understand that the
issuance of this permit does not remove the owner's responsibility for compliance with local, state, or federal laws regulating
construction or environmental laws.
I further agree to hold harmless the City of Federal Way as to any claim(including costs, expenses, and attorneys'fees incurred in
the investigation and defense of such claim), which may be made by any person, including the undersigned, and filed against the city,
but only where such claim arises t of the reliance of the city, including its officers and employees, upon the accuracy of the
information supplied to the c y part of this application.
SIGNATURE: /� DATE
M
PRINT NAE: M4� 64-,(e.,,,,4 4/
Bulletin#100-January 1,2013 Page 1 of 3 k:\Handouts\Permit Application